Patient Safety: What Went Right During COVID-19

by Laura Hoffman, DNP, RN, CPHQ

Performance Improvement Program Director

You may have heard the saying, “Don’t look a gift horse in the mouth.” It generally means you receive something unexpected yet appreciated. While there has been frequent and significantly negative news associated with COVID-19, when it comes to safety, many hospitals have seen their “gift horse” or, perhaps more appropriately, a silver “safety” lining to this pandemic.

Because health care organizations generally have strong safety protocols, process changes are usually driven by what went wrong. Undoubtedly, improvements are being made throughout the COVID-19 pandemic based on this pattern. However, hospitals are reporting that many changes are occurring based on what went right.

One very important way hospitals connect and learn from each other is by attending weekly safety huddles. The huddles are constructive opportunities for safety leaders and clinicians to discuss concerns openly, honestly and in real-time to expedite learnings and process improvements. The huddles are a very powerful tool for the participants. Among the unexpected successes they are experiencing during the pandemic are effectiveness of telehealth in care planning of behavioral health patients, consideration of elimination of certain ineffective nurse double checks and improved teamwork through virtual root cause analyses.

Innovative use of telehealth in patient care planning

Telehealth services quickly went from a new technology still in limited use to an essential care delivery mechanism for many organizations. It has become so essential in fact that CMS broadened telehealth reimbursement coverage making accessing care easier for both providers and patients while reducing risk of exposure to Covid-19. Health care organizations have further expanded its use to successfully conduct behavioral health interdisciplinary rounding and care planning activities.

One organization quickly shifted to the use of telepsychiatry enabling psychiatrists to virtually consult with hospitalized patients suffering from anxiety, social isolation, and confusion as a result of COVID-19, while eliminating the need for face coverings, which ultimately enhanced the therapeutic milieu. The innovative use of telepsychiatry to improve mental health access and reduce antipsychotic medication use for nursing home residents is getting national attention from the Agency for Healthcare Research and Quality (AHRQ). Telehealth or telepsychiatry addresses concerns for patient access to mental health professionals, which is especially useful during the pandemic.  

Safe elimination of independent double checks

What started as a method to conserve personal protective equipment (PPE) at a member hospital has resulted in a successful, and safe, way to conserve additional valuable resources. Independent double checks are activities that require two nurses to independently check the accuracy of a procedure or process against the provider’s order prior to delivery. The Institute for Safe Medication Practices (ISMP) asserted that judicious, selective and proper use of manual independent double checks can be an important component of medication safety. After analyzing current workflow, existing medication guardrail technology, safety data, PPE availability, and other pertinent variables, the hospital challenged their status quo and chose to eliminate the independent double checks for intravenous infusion rate changes. Over 10,000 independent double checks per month were avoided with no reported safety events as a result which reinforced the hypothesis that the infusion rate change process was an inefficient safety layer that provided little benefit. For this organization, these results translate into a valued opinion of judicious, selective and proper use of independent double checks, and reduced exposures to potential COVID-19 positive patients, while preserving vital PPE. Decisions regarding whether and how to utilize any of these practices should be made by health care providers, at their own risk, with consideration of individual circumstances

Virtual root cause analyses

The Joint Commission defines root causes analyses (RCAs) as structured methods used to analyze and identify contributory factors in serious events. They are widely used in health care systems as an event analysis tool. In-person meetings were the traditional way to conduct RCAs and often required participants to travel to a central location. Amid COVID-19, hospitals found themselves struggling with how to conduct meaningful RCAs given the restrictions of social distancing. Many began conducting RCAs virtually with noted improvements in attendance, level of engagement, collaboration, and action planning versus traditional in-person meetings. This small change meant that quality, safety, and risk teams could continue meaningful safety reviews amidst a seemingly chaotic environment.

J. Wears, Braithwaite and RL Hollnagel once wrote that everyday performance in health care succeeds much more often than it fails and that regarding patient safety, the key is to take efforts that enable things to go right. Even in the crux of a pandemic, these hospitals are shining examples of what can happen when we concentrate on what went right! Patients are getting the mental health services they need. Nurses are avoiding virus exposure, conserving critical PPE and finding value in judicious use of independent double checks. . Root cause analysis review teams can remain effective and committed to reviewing safety events. As you ponder your organization’s post-COVID-19 world, what will your patient care planning, nursing workflows, and safety reviews look like? As you envision your future, don’t forget to stop, admire, and learn from what went right!

Vizient works with member hospitals through its Patient Safety Organization to offer resources to improve patient safety, healthcare quality and outcomes.  Member collaboration with similar organizations accelerates the pace at which they improve outcomes.  In addition, enrollment is open for two projects in 2020 that directly focus on safety, and allow members to work collectively with other members: Components of High Reliability Benchmarking Study and Workplace Violence Collaborative.